Behavioral Health Utilization Management Reviewer

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🔥 0 minutes ago

🍂 Massachusetts – Remote

🍂 Massachusetts – Remote

💵 $89.6k - $121.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Baystate Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1873

🧘 Wellness

📚 Education

🤝 Non-profit

Wellness • Education • Non-profit

Baystate Health is a regional integrated health system serving western Massachusetts, providing hospital-based and outpatient care including emergency services, primary and specialty care, surgery, oncology, cardiology, pediatrics, radiology, and maternal health. It operates multiple hospitals and clinics, runs community health and wellness programs, conducts clinical research and trials, and serves as the regional campus for UMass Chan Medical School with extensive medical education and residency programs. Baystate also offers patient-facing digital tools (MyBaystate), fundraising through a foundation, and community outreach and volunteer initiatives.

📋 Description

• Perform medical necessity utilization management and care coordination activities that promote quality, cost-effective, evidence-based behavioral health care. • Review behavioral health services for medical necessity using nationally recognized clinical criteria. • Conduct pre-authorization, admission, concurrent, retrospective, and discharge reviews for inpatient and outpatient behavioral health services. • Evaluate the appropriateness of requested levels of care and treatment plans. • Collaborate with physician reviewers on cases requiring medical necessity determinations or denials. • Research and obtain additional clinical information needed to support utilization management decisions. • Assess requests for out-of-network services when appropriate. • Proactively support discharge planning to ensure seamless transitions across the continuum of care. • Partner with providers, and interdisciplinary teams to coordinate behavioral health services and transitions of care. • Facilitate referrals to community-based services and internal care management programs. • Assist with provider and member appeals related to behavioral health services. • Participate in quality improvement initiatives, clinical projects, and departmental workgroups. • Contribute to the development and revision of departmental policies and procedures. • Maintain accurate, objective, and timely documentation supporting clinical decisions.

🎯 Requirements

• Master’s degree in social work (MSW) or equivalent behavioral health clinical education. • Current licensure as one of the following in the state of Massachusetts : LICSW LCSW LMHC Licensed Psychologist Registered Nurse (RN) with behavioral health experience • Three to five years of behavioral health clinical experience. • Working knowledge of DSM-5 diagnostic criteria. • Familiarity with ASAM Criteria and behavioral health medical necessity guidelines. • Understanding of psychotropic medications and behavioral health treatment modalities. • Knowledge of regional behavioral health resources and community services. • Strong clinical assessment and critical thinking skills. • Excellent written and verbal communication skills. • Experience utilizing electronic utilization management or care management systems.

🏖️ Benefits

• Health insurance • Professional development opportunities • Paid time off